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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1080935-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-3676 Suspected Maltreatment Reported: It was reported that while a staff person (SP) was asleep, two vulnerable adults (VA1 and VA2) were involved in a physical altercation during which VA1 stabbed VA2. Date of Incident(s): May 1, 2026 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on May 27, 2026; from documentation at the facility and law enforcement records; and through six interviews conducted with VA1 and VA2, a supervisory staff person (P1), VA1’s and VA2’s case managers (CM1 and CM2 respectively), and the SP. The facility was a single-family home with two levels. There were three bedrooms on the main level, as well as a kitchen, dining room, and living room. There was one bedroom and a staff office on the lower level. VA1’s bedroom was downstairs, and VA2’s bedroom was on the main level. There were no other residents living at the facility at the time of the incident. VA1 was diagnosed with other specified intracranial injury without loss of consciousness, diabetes, seizure disorder and schizoaffective bipolar disorder. Staff persons assisted VA1 with managing his/her medications, monitoring dietary orders, and managing finances. VA1 enjoyed going for walks, bike rides, and watching television. VA1 was not subject to guardianship. VA1’s Risk Assessment said VA1 did not present a risk of abusive behaviors towards him/herself and/or others, required twenty-four-hour awake supervision, but could be unsupervised at the facility for four hours. VA1 was mobile but used a walker and/or cane to aid in his/her stability. VA1’s primary language was not English. There was no information in VA1’s plans that sharps were required to be locked up. VA2 was diagnosed with schizoaffective disorder and enjoyed playing video games, reading comics, visiting with family and friends, and going for walks. VA2 was not subject to guardianship. VA2’s Risk Assessment said that VA2 was “not always” an accurate provider of information dependent on his/her mental health and could “misinterpret situations and fixate on misinformation.” VA2 had a history of violent behaviors towards others and refusing to take his/her medication which caused an “immediate decline” in VA2’s mental health. VA2 could be unsupervised both at home and in the community for twelve hours but required overnight supervision. There was no information in VA2’s plans that sharps were required to be locked up. The SP provided the following information: · On May 1, 2026, at 9 p.m. the SP began work. VA1 and VA2 were in their bedrooms so the SP went into the office. Around 10:15 p.m., VA1 came into the office and asked if s/he could have a snack and shortly after, VA1 came back downstairs with a container of blueberries. The SP and VA1 then spoke briefly, and the SP believed VA1 returned to his/her bedroom. At this time, the SP was not aware that VA1 went back upstairs, and around 10:45 p.m., the SP heard VA2 “yelling” which was not unusual, but VA2’s dog was barking which was “unusual,” so the SP went upstairs. The SP thought it took him/her around one minute to get from the office to upstairs, because s/he stopped at the bottom of the stairs to listen “for a few seconds.” · Once upstairs, the saw VA1 and VA2 in the dining room area. VA1 was on one knee, with a knife in his/her hand and VA2 was standing approximately ten feet away from VA1. VA2 was yelling at VA1, but the SP could not remember what VA2 said, but VA2 seemed “very angry.” VA1 “didn’t really say anything.” · The SP asked VA1 to put the knife down but was unsure if VA1 heard the SP or “ignored” the SP, because VA1 did not put the knife down. The SP then moved towards VA1 and VA2 to intervene. At that time, VA1 “ran” at VA2 with the knife. VA2 tried to grab VA1’s arms to “hold” VA1 off, and VA1 and VA2 “wrestled around.” At some point, VA2 “tackled” VA1 to the floor, grabbed the knife and threw it away from VA1. · The SP then stood between VA1 and VA2 before s/he separated each to their bedrooms. After VA1 and VA2 were separated, the SP removed the knife from the dining room as well as all knives from the kitchen and locked them in the office. · The SP called P1 and told him/her about the incident. P1 told the SP to call 9-1-1, and the SP did so. The SP then stayed downstairs to ensure VA1 stayed in his/her bedroom until law enforcement arrived. · Around 11:30 p.m., a law enforcement officer (LEO) arrived and spoke with VA1 in his/her bedroom while the SP went upstairs and spoke with VA2 in his/her bedroom. VA2 told the SP that VA1 hit VA2’s dog, which started an argument. VA2 was “shocked” that VA1 went after him/her with a knife. While the SP and VA2 spoke, VA2 realized s/he had an injury and lifted his/her shirt. The SP saw what s/he thought was a “stab” wound, “maybe” the size of a quarter, on VA2’s lower left chest. The SP took photos of the injury and sent them to P1. After speaking with VA2, the SP spoke with the LEO who said that VA1 was being arrested and taken to jail. · VA1 was usually asleep when the SP worked, and the SP did not know VA1 to be “violent” prior to this incident. VA1 did not like VA2’s dog, but the SP was unsure why. · VA2 had a history of “anger issues” and physical aggression and was often angry about things s/he thought were real but were not really happening. VA2’s dog was “rowdy,” but the SP had not seen the dog attempt to harm anyone. · The SP said that although s/he had previously fallen asleep when s/he worked, s/he denied being asleep when the incident occurred and responded as soon as s/he heard VA2’s dog barking. The SP denied that VA2 had a knife, aside from when s/he removed the knife from VA1 and denied placing a blanket over VA1’s head at any point during the incident. Photos of VA2’s injury showed a wound on VA2’s left chest, above his/her ribs, which appeared to be the size of a quarter. VA2 also had a small scratch on his/her left hand, near his/her thumb. A photo of the knife showed it was a kitchen knife, with a broken black handle. Attempts were made via telephone to verify the size of the knife, however, were unsuccessful. P1 provided the following information: · On or around May 8, 2026, P1 attended VA1’s court hearing regarding the incident via zoom, during which, VA1 said the SP was asleep when the incident occurred. However, VA1 did not have a translator during this hearing, and the comment was “really broken up” so P1 was unsure exactly what VA1 said. Following the hearing, P1 shared this information with a supervisory staff person. · Both VA1 and VA2 required awake overnight supervision, and the facility was staffed as such. · P1 did not believe either VA1 or VA2 were accurate providers of information due to their diagnosis. VA1 initially said that when the incident occurred, s/he did not know where staff persons were and that there were three or four staff persons working but they all were asleep. Later VA1 stated that the SP “might have” slept on the couch downstairs. VA1 was afraid of VA2’s dog, and just prior to the incident, the dog “ran up on” VA1 so s/he kicked a ball towards the dog. VA2 then “came up” on VA1 but then turned around and “ran” to his/her room to get his/her black knife. The SP came upstairs “not long” after s/he heard VA1 and VA2 arguing. The SP separated VA1 and VA2 and told each of them to go to their bedrooms and then called 9-1-1. VA1 said VA2 had a knife and “waved” it in his/her hand but did not do anything with the knife. VA1 did not know if the SP saw VA2’s knife, because the SP threw a blanket over VA1’s head. VA1 thought the SP put a blanket over his/her head to “deescalate” the argument, which the SP had not done before. VA1 did not provide additional information regarding the incident due to the ongoing criminal investigation. VA2 said VA1 walked upstairs at the facility and “slapped” VA2’s dog, which started an argument between them. At some point, VA1 held a “butcher” knife, and there was a scuffle. VA2 did not remember being “sliced” by VA1. At some point, VA2 “slapped” the knife out of VA1’s hand and then the staff person working stood in-between VA1 and VA2. VA2 said s/he “healed up” right away. VA2 did not provide additional information regarding the allegation. Law Enforcement Records and the facility’s Internal Review provided the following information: · On May 1, 2026, at 11:29 p.m., the SP called 9-1-1 and reported that VA1 assaulted VA2. · When the LEO arrived at the facility, VA2 told the LEO that VA1 “stabbed” him/her with a knife. VA2 had a stab wound, approximately three quarters of an inch long, near his/her left nipple and had “some blood” near the wound. VA2 was assessed by emergency medical technicians (EMT), but “refused” additional medical care. · The SP told the LEO that s/he was downstairs in the office when s/he heard VA1 and VA2 arguing upstairs. The SP went upstairs and saw VA1 on one knee with a knife in his/her hand. The SP talked to VA1 and asked VA1 to put the knife down, but VA1 did not do so. VA1 then stood up and “went after” VA2. VA2 “knocked [VA1] down,” grabbed the knife and threw it, at which time the SP separated VA1 and VA2 and had them go to their bedrooms and then “secured” the knife in the office. The SP thought the incident lasted two to three minutes. · The SP gave the LEO the knife, which was a “standard kitchen knife often used for cutting lettuce.” The handle of the knife broke when VA2 threw it. · The LEO spoke with VA1, who was “unarmed and cooperative.” VA1 was unable to provide the LEO information due to a language barrier but based on VA2’s and the SP’s account of what happened, VA1 was arrested and charged with second degree assault and felony domestic assault. The facility’s Shift note Summary from May 1, 2026, showed that when staff persons arrived at the facility at 5 p.m., both VA1 and VA2 were in their bedrooms. VA2 remained in his/her bedroom the entirety of the shift, and VA1 only left to take his/her medications and smoke. There were no noted incidents regarding VA1 during that shift, and it was noted that earlier in the day, VA2 was “upset” and “talked loudly” the majority of the morning. CM1 was aware of the allegations and did not have previous concern with the facility. CM1 was not aware of VA1 having a history of physical aggression and thought the incident “came out of left field.” CM2 was aware of the allegation and did not have previous concern with the facility. CM2 did not believe VA2 was an accurate provider of information and said that VA2 often said “outlandish” things. The facility’s personnel files showed that P1 and the SP were trained on facility policies and procedures, VA1’s and VA2’s plans, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: The SP provided consistent information that on May 1, 2026, around 10:45 p.m., the SP was in the basement office when s/he heard VA1 and VA2 arguing and VA2’s dog barking. The SP went upstairs and saw VA1 with a knife. VA1 and VA2 got into a physical altercation that resulted in VA1 stabbing VA2. The SP intervened and separated VA1 and VA2 and then called P1 and 9-1-1. There was no information in VA1’s or VA2’s plans that either required eyes on supervision while at the facility or that sharps including knives needed to be locked up. P1 said that during VA1’s hearing, VA1 may have said that the SP was sleeping. However, VA1 provided inconsistent information during his/her interview regarding how many staff persons were present during the incident and who was sleeping. The SP denied being asleep when the incident occurred and stated that it took him/her around one minute from when s/he heard the arguing and dog barking to when s/he got upstairs and intervened. Given that VA1 provided inconsistent information; and that the SP denied sleeping, immediately intervened separating VA1 and VA2, and then called 9-1-1, there was not a preponderance of evidence whether there was a failure or omission to supply VA1 and VA2 with reasonable and necessary care or services. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. Staff persons were retrained on shift expectations and the facility’s Program Abuse Prevention Plan. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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